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West Reading Radiology Associates
Reading, PA
19612-6052
García-García and Lanciego [1] are to be commended for their favorable report of percutaneous biliary stone treatment using balloon sphincteroplasty and transpapillary stone expulsion. For nearly a decade, this has been my technique of choice, and I have been equally impressed with its efficacy, safety, and simplicity.
I would question the authors, however, in their assertion of cost-effectiveness. Although clinical utility has clearly been established, none of the commonly accepted models of economic analysis [2] has been used. In fact, specific costs are not mentioned in the article. Showing clinical effectiveness does not necessarily translate to cost-effectiveness. The technique may well be cost-effective, but no data are presented to support such a claim.
In the general medical community, basic principles of cost evaluation are poorly understood [3]. The oft-asserted term "cost-effective" is frequently misused [4], commonly in the absence of explicit cost data. In this regard, the authors are not unique.
As long as the use of diagnostic and interventional radiology services increases, payers continue to critically analyze the return on their imaging dollars. Good economic research will be needed for radiologists to show the value of our services. Although such research skills are not expected of most clinical practitioners, all physicians need a basic understanding of what cost-effectiveness is (and is not). Quite simply, it means that a service has some benefit worth its additional cost [4]. Without actually measuring that cost, cost-effectiveness cannot be calculated.
References
Hospital "Virgen de la Salud"
Complejo Hospitalario de
Toledo
Toledo 45004, Spain
We are pleased and encouraged by the response to our article [1] by Dr. Richard Duszak, Jr., of Reading, PA.
Duszak says he has used for a considerable period of time the method we recommended. Like us, he has been satisfied with the clinical success and the relatively low cost of the procedure [1]. What he does dispute, however, is our choice of term "costeffective" [2]. In draft versions of our article, we had used terms of economic analysis that are widely accepted, such as "diagnosis related groups" and "unit of relative value scale," and that are used by the appropriate specialists in the economic administrative department of our hospital, but we removed those passages at the suggestion of a reviewer. The data we had generated would have had some relevance to the American audience of AJR precisely because the units used in the assessments are universally applicable and not confined to Spain, or to Europe, for that matter [3]. We are familiar with this type of analytic accounting and, indeed, have applied it in other studies conducted by our clinical research group [4, 5].
We agree that, in general, the term "cost-effective" has been overused [6]. The term should only be applied to specific analyses involving not just the effectiveness of a procedure but also the added value of a lower cost, relative to a comparable procedure. However, according to Doubilet et al. [6] another criterion "corresponds best to our intuitive sense of cost-effectiveness in that it takes into account both cost and effectiveness and the tradeoff between them. Programs that either improve health outcome and save money or deliver a health benefit at an acceptable cost will—appropriately—be considered cost-effective according to this criterion."
We appreciate that the United States has critical differences in health funding that increase the importance of phrases such as "medical decisions should be based on cost-effectiveness criteria" and "the decision-making process in the United States includes relationships with managed-care organizations, insurance companies, and private hospital or government criteria." Spain (and Europe) have not been as focused on such aspects, so far, but are becoming increasingly so. It was for this reason that we wanted to retain some of these aspects in our original manuscript.
Finally, we regret that we are unable to refute Duszak's point in his letter to the editor because he is, indeed, correct in his criticism. However, we hope that these explanations can serve as an acceptable response to him and other readers to whom the use of the term "cost-effective" in our article seems somewhat strange.
We look forward to your views.
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